2017 ACP Colorado Chapter Residents’ Meeting May 16, 2017 Saint Joseph Hospital, Denver, Colorado Broadmoor Hotel, Colorado Resident Abstracts Presented: May 16, 2017 2017 ACP Colorado Chapter Residents’ Meeting- May 16, 2017– Saint Joseph Hospital, Denver, Colorado Name: Jacob Ludwig, DO Presentation Type: Oral Presentation Residency Program: Saint Joseph Hospital Additional Authors: Abstract Title: Pharming Abstract Information: Case Study: YK is a 19 y/o female with intractable seizures who presented to the epilepsy-monitoring unit for further evaluation after failing to respond to antiepileptic drug (AED) therapy. YK’s neurological issues began at 15 y/o, which included tremor, difficulty concentrating and episodic involuntary limb/torso movements. These movements progressed after starting high school often triggered by studying, focusing, reading or playing piano. At age 18, YK began complaining of worsening insomnia and depression, and her father began noticing focal seizures that would progress into generalized bilateral convulsions with loss of consciousness. YK’s father noted that the seizures often occurred around the 20th of every month despite increasing doses of Levetiracetam. At age 19, YK’s seizures became more frequent and she experienced worsening of symptoms that included colorful visual hallucinations. Her insomnia and depression were treated with amitriptyline and her AED medications were changed to Lamotrigine and Topiramate. But her seizures continued to be refractory despite increased AED doses. YK then presented to the epilepsy-monitoring unit for further work-up. Throughout the first day of monitoring, she suffered numerous brief seizures, periods of hemodynamic instability, and had a negative lamotrigine serum drug level. On hospital day 2 she had a prolonged seizure aborted with ativan. A CNA then discovered numerous diphenhydramine pills underneath her in a recliner chair. The neurologist reviewed the recorded video, which revealed YK taking several handfuls, 300-500 mg at one time, of diphenhydramine pills overnight and, notably, one hour before her prolonged seizure. YK was subsequently intubated and sedated with propofol for seizure control, which was transitioned to Phenobarbital. Her AED’s were increased and changed to IV formulations. She remained mechanically ventilated for several days with frequent hyperkinetic movements, hemodynamic instability, fevers and urinary retention, but without further seizure activity. Her QRS remained stable, her symptoms eventually subsided and she was successfully extubated. YK eventually endorsed taking 5 tablets of diphenhydramine usually 3 times daily beginning at 15 y/o. Her initial motivation was insomnia, but she added daytime doses to help with allergies. She then began experiencing a “high,” which prompted her to take more. In the week prior to admission, she also started taking antler tea, a Korean homeopathic remedy for her seizures. Her depression and insomnia were worsening, and her seizures were even more frequent, so she again increased her diphenhydramine intake in conjunction with suicidal ideations. She was ultimately discharged in stable condition to inpatient psychiatric care for further evaluation. Discussion: With advancements in biotechnology and imaging the ability to determine a patient’s specific epilepsy etiology has improved, often identifying genetic, structural or metabolic causes. However, the etiology of up to one third of all cases remains unknown. YK’s epilepsy was associated with strange features that included visual hallucinations, altered mental status, urinary retention, hyperkinetic movements and hemodynamic instability, and was refractory to several antiepileptic drugs. When it was discovered that her seizures were from chronic daily diphenhydramine overdose the picture came together and she ultimately endorsed motivations for use that included insomnia, depression, intoxication and suicidal ideations. She was also taking amitriptyline, which undoubtedly worsened her anticholinergic state, and also had absent blood levels of lamotrigine, likely due to alterations in drug metabolism from the herbal tea. The controversial antidotal therapy of physostigmine, an acetylcholinesterase inhibitor, was not used given its risk of precipitating more seizure activity. Diphenhydramine abuse is common, especially as treatment for insomnia and for intoxicant effect, and symptoms associated with the anticholinergic overdose are dose- dependent. With ingestion of greater than 300-1000 mg daily, symptoms can include visual hallucinations, seizures, coma and life threatening QRS or QT prolongation. “Pharming,” or the use of prescription or OTC drugs for intoxication purposes, among teens has been trending up in recent years. Recreational use of diphenhydramine for hallucinogenic effect is reported in the literature at doses of 300-700 mg. Furthermore, with chronic use, addiction ensues and withdrawal symptoms can be very distressing. YK was likely using similar doses for a year or more, and her chronic ingestion was nearly fatal. Luckily the etiology of her epilepsy remained under investigation. Through the efforts of diligent physicians, assisted by advances in technology, the cause of her seizures was ultimately determined and she is now receiving the psychiatric care that she truly needs. 2017 ACP Colorado Chapter Residents’ Meeting – May 16, 2017, Saint Joseph Hospital, Denver, Colorado Name: Jan Denkmann, MD Presentation Type: Oral Presentation Residency Program: Saint Joseph Hospital Additional Authors: Eric Seger, DO Abstract Title: A Rare Case of Motor Neuropathy Abstract Information: Case Case Description 58yo male presented with a 3 week history of a rash, subjective fever and chills, night sweats and nausea for more than 48 hours. He also noted enlarged lymph nodes in in his neck for 3-4 months and an enlarging right neck mass for the past 6-8 weeks. Past medical history was limited to untreated hypertension and depression.. He has a remote history of smoking, drinking, cocaine and marijuana abuse in the 1970’s. Physical exam was remarkable for enlarged bilateral anterior cervical lymph nodes, a diffuse vesicular rash with innumerable erythematous papules, in different stages of development including eschar, closed, pustular, and hemorrhagic lesions noted on face, scalp, torso, arms and legs. Oral mucus membranes of his lower lip demonstrated a single painful blister, and there was no conjunctival involvement. Neurologic assessment on the day of admission was significant for RUE weakness of the shoulder with 2/5 strength for abduction and extension. Laboratory evaluation was significant for a lymphocytic leukocytosis (WBC 105K, Lymphocytes 92%) with noted smudge cells on peripheral blood smear. A peripheral blood flow cytometry showed a population of monotypic B cells with a phenotype consistent with chronic lymphocytic leukemia. Chemistry was significant for mild hyperkalemia (5.1 mmol/L), elevated creatinine (1.48 mg/dL) and elevated uric acid (7.3 mg/dL). Virology assessment included negative PCR for HIV and HSV 1 and 2. The pathologic assessment of the skin biopsy showed changes to keratinocytes consistent with VZV. Treatment was initiated for acute VZV infection with one dose of IVIG and a 14 day course of IV acyclovir. His treatment course was complicated by multiple catheter- associated superficial thrombophlebitides and acute kidney injury on day 12 that necessitated dose reduction of acyclovir. The patient was provided aggressive physical therapy for his motor neuropathy and regained full strength in his left shoulder. The right-sided motor neuropathy persisted, and he was discharged with home physical therapy. Case Discussion Immunocompromised patients are at increased risk for disseminated VZV infection. This is more commonly seen in transplant recipients on chronic immunotherapy and advanced HIV-infection. This patient presented with previously undiagnosed chronic lymphocytic leukemia, which put him at risk for disseminated infection. Complications of disseminated VZV infection may include visceral organ involvement including disease patterns of pneumonia, hepatitis and encephalitis. The most common neurologic complications are Ramsay-Hunt syndrome and segmental limb paresis. Peripheral motor neuropathy is a relatively rare complication and thought to occur in approximately 3% of patients with VZV infection. The peripheral motor weakness is thought to result from a spread of VZV from the dorsal root ganglia to the anterior root/horn. Treatment options for VZV most commonly include intravenous vidarabin or acyclovir and PT rehab for motor strength training. 2017 ACP Colorado Chapter Residents’ Meeting, Saint Joseph Hospital, Denver, Colorado Name: Kristin Hesterberg, DO Presentation Type: Oral Presentation Residency Program: Saint Joseph Hospital Additional Authors: Rachel de Andrade Pereira, MS Abstract Title: Rare Cause of an Unresponsive Patient Abstract Information: Case A previously healthy 58-year-old male presented for revision of left hip arthroplasty. Surgery was prolonged with significant bone manipulation. Patient received spinal anesthesia only, without paralytics agents. Intra-operatively, he developed atrial fibrillation. Rate was controlled with esmolol and he converted back to sinus rhythm. Blood pressure remained stable throughout procedure. Intra- operatively, he received, fentanyl, propofol, lidocaine, tranexamic acid, ketamine and 2.5 liters of LR solution. Post-operatively the patient was